Provider Demographics
NPI:1033454335
Name:AMADI, AUGUSTA
Entity Type:Individual
Prefix:
First Name:AUGUSTA
Middle Name:
Last Name:AMADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14101 SULLYFIELD CIR
Mailing Address - Street 2:SUITE 400A
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1625
Mailing Address - Country:US
Mailing Address - Phone:571-512-7287
Mailing Address - Fax:
Practice Address - Street 1:14101 SULLYFIELD CIR
Practice Address - Street 2:SUITE 400A
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1625
Practice Address - Country:US
Practice Address - Phone:571-512-7287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132384163W00000X
MO2012021032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse